1.

Dedi Asmara/M/42years/MW24 Laboratorium

Chief Complaint : increasing frequent of nausea and vomiting Hb 12.0 Albumin 3.3
• increasing frequent of nausea and vomiting, frequency more than 10 times since yesterday Ht 29 Ureum 14
• Diarrhea since 2 days, pulp is absent, odorless, not slimy and bloodless
• reduced appetite, feels thirsty Leukosit 10980 Kreatinin 0.3
• body feels weak and tired since these 2 days Trombosit 126.000 Natrium 94
• no fever, no shortness of breath, no chest pain
The urinary is murky DC 0/0/90/6/4 Kalium 1.7
•
• The patient has been known to be a nephrotic syndrome patient since 1 years ago and controls 1 time a month to the internal
medicine doctor at the hospital Dabok Kepri
PT 10.9 Clorida 43
• History of Disease: Hypertension, no history of Diabetes Mellitus
• History of Drugs: ramipril 1x2.5 mg, furosemide 1x40 mg, metylprednisolon 2x8 mg APTT 24.6 SGOT 31
• General appearance :moderate, Consciousness level : CMC, BP : 87/57-->137/80 mmHg, Pulse :92x/min, RR : 20 INR 1,01 SGPT 32
x/minute,
T :36 oC SPo2 : 98 % BW: 54 kg, Height: 160 m BMI: 21,09kg/m2
Eye: conjunctiva anemic (-) Sclera icteric (-) , oedema periorbital +/+
JVP: 5-2 cm H2O
Cor: Inspection: ictus is not seen. Palpation: ictus is palpated at 2 finger medial LMCS ICS VI
Percussion: Left border: 2 finger medial of LMCS VI Right border: Linea sternalis dextra Upper border: ICS II
Auscultation: Heart sound I and II regular, murmur (-)
Pulmo: Inspection: symmetric right = left Palpation: normal fremitus right = left Percussion: sonor, Auscultation: vesicular, Rh
-/- Wh -/-,
Abdomen Inspection: Enlargement (-). Palpation: hepar and spleen are not palpated,pain (-) Percussion: tympani Auscultation:
increasing bowel sound (+)
Extremity : decreased skin turgor, warm extremity +/+
others : daldiyono score : 5
Diagnosis : GEA with moderate dehydration
Hyponatremia hypoosmolar hypovolemia ec GI loss
Hypokalemia ec GI loss
AKI stage II
RBBB Inkomplete
Nephrotic Syndrome on theraphy
 Problem Therapy Plan
• GEA with moderate  Rest/ Torelable Diet Low Salt Low Protein  check profile lipid
dehydration  IVFD NaCl 3%/ 12 hours, plan -> 4 kolf
• History of Nephrotic  KCl drip 50 meq in 200 cc Nacl 0,9% in 4 hours
Syndrom  Loperamid 2x1
• Hypoalbumin  Lansoprazol 1x30 mg
• Hyponatremia  Domperidon 3x1 tablet
• Hypokalemia  Metoklopramid ekstra 1 tablet
 methylprednisolone 2x8 mg po
 ramipril 1x2,5 mg po